Objective: To develop a low-cost 3D-printed Laryngeal Injection Task Trainer (LITT) for simulation of transcutaneous injection laryngoplasty and evaluate its effectiveness among trainees. Methods: Design: Cross-Sectional Time-Motion Study and Post-Training Evaluation Survey Setting: Tertiary University College of Medicine Anatomy Laboratory Participants: Five residents and 2 consultants in Otolaryngology-Head and Neck Surgery were trained using a LITT fabricated through three-dimensional printing of cartilage models and silicone molds through the UP SIBOL Greenhouse and the Philippine General Hospital Craniomaxillofacial Prosthesis Unit. Participants were asked to perform transcutaneous laryngeal injection on the LITT. The duration in performing the procedure from palpation of landmarks to injection of material was measured in seconds and recorded. After the simulation workshop, participants were asked to evaluate the subjective experience with surgical simulation using the modified Michigan Standard Simulation Experience Scale (MiSSES). Results: The mean time in performing transcutaneous laryngeal injection across different training levels for either trans-cricothyroid or trans-thyrohyoid approach was not statistically significant. Mean time in performing transcutaneous laryngeal injection between 2 approaches, the trans-cricothyroid approach (79.32 seconds with SD 34.89) and the trans-thyrohyoid approach (35.16 seconds with SD of 10.88), was statistically significant. Using the MiSSES tool for evaluation of the simulation training, majority of the participants agreed that the LITT allowed self-efficacy in performing the procedure, had adequate fidelity in terms of its characteristics and components, had high educational value in training participants for knowledge and skills on transcutaneous laryngeal injection and that the simulation provided good teaching quality. For the overall rating, all participants concurred, with 83.3% of participants answering strongly agree and 16.7% of participants responding somewhat agree, that the simulation experience was helpful in knowledge and skills development on transcutaneous laryngeal injection. On final evaluation of the LITT, 75% of the participants responded that it can be used in training but should be improved slightly. Conclusion The laryngeal injection task trainer (LITT) had an acceptable fidelity, educational value, teaching quality to improve self-efficacy in performing transcutaneous injection laryngoplasty - with points for improvement in terms of model and set-up stability, color accuracy and consistency of the visual indicator. It is recommended that the LITT be also used for future workshops and possibly further validation studies after applying the points for improvement gathered from this simulation study.

Background and Objective: The COVID 19 pandemic has changed the way the human anatomy is taught. A necessary shift towards online instruction, combined with a decrease in cadaver donation has resulted in the need for maximizing formalinized, soft-embalmed, computerized, and plastinated cadaver specimens. Task-oriented activities allow students to demonstrate acquired knowledge and skills. It is the aim of this study to get the perspective of students in the utilization of available laboratory materials. Methods: One hundred forty-three students participated in task-oriented activities. Students demonstrated anatomy of the facial nerve, recurrent laryngeal nerve, and phrenic nerve by parotidectomy, thyroidectomy, and posterior neck dissection using formalinized cadaver and VH dissector™. Deep neck and sagittal structures in the plastinated specimen were identified using laser pointers. Ossicular mobility of the middle ear, and endoscopy of the nose and larynx were demonstrated using the soft embalmed cadaver. Students were surveyed on their perceptions on the utility of each cadaver specimen. Results: Formalinized and soft-embalmed cadaver were observed to present the most accurate anatomy, while the virtual dissector and plastinated specimens were seen to be the most sustainable and reusable. Conclusion Task-oriented learning in head and neck anatomy may use different cadaveric materials with varied accuracy and utility.
Anatomy ; Cadaver ; Education, Medical

Background and Objective: The pandemic has forced medical education to adopt online and hybrid set-ups, and this has greatly changed the way human anatomy is taught. Course-required knowledge can be accessed using raw references like original publications, collected reviews such as those found in books, as well as in shorter versions like summaries, and in online or electronic applications or software. With readily accessible online physical materials and human resources in anatomy, the value of learning by seeking out verifiable information to answer a real time query may change the current method of teaching and assessment of outcome-based learning in a heavy-recall subject such as human anatomy. For the student, sources of information or instruction are termed the “peripheral brain”. The objective of this study is to describe the medical students’ method in accessing medical information during a hybrid small group discussion. Methods: In a modified hybrid laboratory set-up, a class of 200 students were divided into 18 groups, with two students in each group acting as laboratory dissector, who will broadcast their in-person classroom activities to the group members via zoom. The groups rotated in nine specimen stations consisting of soft-embalmed cadavers, plastinated specimen, models, bones, and VH dissector™ virtual dissector. Students were allowed to use any type of resources to accomplish the following tasks: 1) look for listed structures, 2) identify landmarks, and 3) describe functions. A Google sheet survey was administered a month after the activity on the following domains: search strategy, targeted references, and verifiability of information. Results: There were 110 students with age range of 19-27 years old, who participated in the study. Their most accessed reference is still personally prepared notes, followed by electronic books. When using ebooks, the first thing students reported exploring is the table of contents, followed by the search button. If doing online search, the key word used is the structure or function of interest. In group dynamics, students prefer to divide the work and assign tasks to each member, instead of collectively and simultaneously discussing a topic. For them, the most important characteristic of a reliable peripheral brain is that it is the recommended reference, followed by how current the reference is, i.e., published in the last 3 to 5 years. Interestingly, for most students, the information must be acquired in 5 minutes, which is contrary to the preferred mode of reference. Artificial intelligence may enhance SGDs according to most of the students. In accessing peripheral brain, Google is perceived as the quickest, books are most reliable, and Pubmed is the most up-to-date. Most of the students preferred pre-assigned questions or tasks during SGDs, with equal distribution of work. Giving and receiving remote instructions is not a problem. Dealing with a difficult group member is important, but is not a problem in hybrid discussion. Conclusion The survey results provide valuable insight on learning strategies used by the current generation of medical students, who have started medical school during the pandemic and are used to online teachinglearning modes of instruction. These findings can be exploited in designing course activities. The concept of peripheral brain in small group discussions can be formally introduced to students learning anatomy to utilize modern technology in enhancing knowledge.
Anatomy ; Education, Medical

Background and Objective: The pandemic acted as an accelerator for the development of online teaching formats in anatomy and histology worldwide. The authors introduce a bridging program that reinforces the knowledge and understanding of gross and correlative anatomy and histology acquired in a virtual environment in preparation for its future clinical application. The study aims to evaluate the Learning Enhancement in Anatomy Program (LEAP) conducted among first-year medical students at the College of Medicine, University of the Philippines Manila. Methods: This descriptive cross-sectional study aims to determine the initial experience of implementing a learning enhancement program and assess areas for its improvement. An internally validated questionnaire was given to students after the program to gauge students’ reactions (Kirkpatrick Level 1 evaluation). Pre- and post-tests were administered to evaluate knowledge acquisition (Kirkpatrick Level 2 evaluation). Short-term behavioral peer evaluation (Kirkpatrick Level 3 evaluation) was also instituted. Results: One hundred fifty-two (152) students participated in the study. General reactions from students to the LEAP were consistently positive, with a steady majority of the students rating ‘5’ or a ‘Strongly Agree’ to positive statements regarding the program. Higher ratings for more traditional teaching methods, such as cadavers, formalinized specimens, and bones, compared to virtual systems were apparent. However, inter-student variation in preference for teaching modalities was observed. All stations of the LEAP were evaluated satisfactorily, with most gross anatomy stations rated higher than histology stations. A significant increase was noted in the total post-test scores compared to pre-test scores. This improvement in test scores was observed in the anatomy and histology subcategories and in six of the seven organ system modules. Perceived behavioral outcomes were also generally positive. Conclusion The LEAP is a worthwhile endeavor, garnering overwhelmingly positive reactions and a significant improvement in test scores. Future studies are necessary to fine-tune teaching and training in a blended learning environment.
Anatomy ; COVID-19 ; Education, Medical ; Program Evaluation

Background. Simulators in laryngology are an essential part of training. They provide an avenue for medical students and resident trainees to practice valuable psychomotor skills outside the realm of an actual patient encounter - thereby decreasing the risk of possible patient morbidity. Herein we present three locally manufactured simulation devices that can be used to train residents in laryngology procedures.

Objective. To present three simulation platform devices (Laser Box, Flexible Endoscopy Simulation, Thiel Cadaver Chair) and their applications in simulation-based learning

Methods. The Laser Box, Flexible Endoscopy Simulation, and Thiel Cadaver Chair were manufactured by outside parties designated as 'Laser Machinists'.

Results. Ten (10) units of the Laser Box, two (2) units of the Thiel Cadaver Chair, and two (2) units of the Flexible Endoscopy Simulation were constructed. They were used in a laryngology postgraduate course in our institution to teach the participants on endoscopies and laser phonosurgery.

Conclusion. Simulation for otolaryngologic procedures should be an essential part of training. The learning curve for procedures such as laryngoscopy and laser phonosurgery can be addressed with the production of simulation platforms. Most institutions in the Philippines still adopt the "see one, do one, teach one" approach, which lacks standardization and puts patients at risk. Various task trainers for laser phonosurgery and flexible endoscopy have been reported in the literature, but there seems to be no published data on the use of a cadaver chair for simulation. In the COVID-19 era, aside from being excellent teaching tools, simulation platforms derive their importance in helping train residents, educate medical students, and review consultants - maximizing skill development - and thereby decreasing repeated attempts, and indirectly, exposure to the SARS-CoV-2. Future validation studies are required for the models, with the eventual long-term goals to further standardize training, increase patient safety and incorporate a simulation-based curriculum for the specialty locally.

Laryngoplasty ; Larynx

Objective. To determine the diagnostic accuracy of self-collected snorted and spit saliva in detecting COVID-19 using RT-PCR (ssRT-PCR) and lateral flow antigen test (ssLFA) versus nasopharyngeal swab RT-PCR (npRT-PCR). Methods. One hundred ninety-seven symptomatic subjects for COVID-19 testing in a tertiary hospital underwent snort-spit saliva self-collection for RT-PCR and antigen testing and nasopharyngeal swab for RT-PCR as reference. Positivity rates, agreement, sensitivity, specificity, and likelihood ratios were estimated. Results. Estimated prevalence of COVID-19 using npRT-PCR was 9% (exact 95% CI of 5.5% - 14.1%). A higher positivity rate of 13% in the ssRT-PCR assay suggested possible higher viral RNA in the snort-spit samples. There was 92.9% agreement between ssRT-PCR and npRT-PCR (exact 95% CI of 88.4% to 96.1%; Cohen’s Kappa of 0.6435). If npRT-PCR will be assumed as reference standard, the estimated Sensitivity was 83.3% (exact 95% CI of 60.8% to 94.2%), Specificity 93.9% (exact 95% CI of 89.3% to 96.5%), Positive predictive value of 57.7% (exact 95% CI of 38.9% to 74.5%), Negative predictive value of 98.2% (exact 95% CI of 95% to 99.4%), positive likelihood ratio of 3.65 (95% CI of 7.37 to 24.9), negative likelihood ratio of 0.178 (95% CI of 0.063 to 0.499). There was 84.84% agreement (95% exact CI of 79.1% to 89.5%; Cohen’s Kappa of 0.2356) between ssLFAvs npRT-PCR, sensitivity of 38.9% (exact 95% CI of 20.3% to 61.4%), specificity of 89.4% (exact 95% CI of 84.1% to 93.1%), PPV of 26.9% (95% CI of 13.7% to 46.1%), NPV of 93.6% (exact 95% CI of 88.8% to 96.4%), LR+ of 3.67 (95% CI of 1.79 - 7.51), LR – of 0.68 (95% CI of 0.47 - 0.99). Conclusion. Our data showed that snort-spit saliva RT-PCR testing had acceptable diagnostic performance characteristics and can potentially be used as an alternative to the standard nasopharyngeal/oropharyngeal swab RT-PCR test for COVID-19 in certain situations. However, our data also showed that snort-spit saliva antigen testing using lateral flow assay did not offer acceptable performance.
Saliva ; SARS-CoV-2 ; Reverse Transcription ; Reverse Transcriptase Polymerase Chain Reaction

Objective: This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. Methods: Design: Retrospective Cohort Study Setting: Tertiary National University Hospital Patients: Seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. Demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. Results: Of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. The three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). Results of multivariate logistic regression analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation. No dependent variable/symptoms had a significant effect in predicting discharge and mortality. Conclusion: Clinically diagnosed tetanus can be easily recognized and immediately treated. Most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. In particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality.
tracheotomy ; tetanus ; trismus ; Neck Pain ; Muscle Rigidity

OBJECTIVE: To determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy.

METHODS:

Design:                Causal-Comparative (ex post facto) Chart Review

Setting:                Tertiary National University Hospital

Participants:                   Records of 68 pediatric patients who underwent elective tracheostomy from January 1, 2013 to June 30, 2018 were considered for inclusion. Patients were excluded if invasive mechanical ventilation was not done prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. Selected patients were categorized in the early tracheostomy group if the procedure was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. Early post-tracheostomy weaning from mechanical ventilation was defined as less than 7 days from time of tracheostomy.

RESULTS: A total of 21 patients were included, 6 in the early tracheostomy group and 15 in the late tracheostomy group. Although early tracheostomy did not show significant association with shortened post-tracheostomy duration of mechanical ventilation (O.R. 6; C.I. 0.276 to 130.322; p = .476), two-sample t-tests showed the early tracheostomy group had a significantly shorter mean duration of mechanical ventilation and hospitalization compared to the late tracheostomy group (13.17 vs. 54.13 days, p = .0012; 21.17 vs. 66.67 days, p = .0032).

CONCLUSION: Although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support, there is a significant difference in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and this may suggest potential benefits of performing tracheostomy earlier in children.

 

KEYWORDS: tracheotomy; pediatric; mechanical ventilation; hospitalization

Human ; Male ; Female ; Adolescent (a Person 13-18 Years Of Age) ; Child Preschool (a Child Between The Ages Of 2 And 5) ; Tracheotomy ; Ventilation ; Hospitalization

OBJECTIVE: To develop a ventilation tube insertion simulator for training and evaluation of otorhinolaryngology residents in myringotomy with ventilating tube insertion.

METHODS:

            DESIGN:            Cross - Sectional Study

            SETTING:           Tertiary National University Hospital

            PARTICIPANTS:   Otologists and otorhinolaryngology resident trainees

A simulation tool for myringotomy with ventilation tube insertion was fabricated using silicone sealant, aluminum tube, rubber ball, plaster of paris and plastic sheet, and pretested by our expert panel. Residents were then evaluated using an objective structured clinical examination (OSCE) checklist while performing the procedure using the same model. Three trials were given, and OSCE scores were obtained, for each resident.

RESULT: The pinna, ear canal, tympanic membrane, malleus handle were deemed realistic by the expert panel. Residents performed the procedure at an average of 87 seconds. Average OSCE score for all residents was 17.17, with senior residents having a higher average score (18.3) than junior residents (16.6). However, this was not statistically significant (2 tailed t-value, significance level 0.05 = -1.27, p = .227). The most common cause of trial failure was dropping of the tube in the middle ear, while the most common error made was using more than 2 attempts at performing the incision.

CONCLUSION:  This simulation platform may be a valuable tool to use in educating and developing skills and proper technique of myringotomy with ventilation tube insertion. It is reproducible, affordable, realistic, sturdy and versatile in its applications. Residents who show adequate dexterity and consistency during simulation may eventually be allowed to perform the procedure on patients and provide feedback regarding the usefulness of the simulation.

Human ; Male ; Female ; Middle Aged (a Person 45-64 Years Of Age) ; Adult (a Person 19-44 Years Of Age) ; Otitis Media With Effusion ; Middle Ear Ventilation ; Tympanic Membrane ; Simulation Training ; Patient Simulation

Laryngosternopexy is a suturing method between the thyroid lamina and sternal ligament in order to relieve tension from the anastomosis when performing segmental resection of the airway.  A thick absorbable monofilament suture is passed through thyroid lamina and the interclavicular ligament of the sternum in a figure of eight fashion as described by Castellanos.1,2 In laryngosternopexy, the suture support is ventral to the anastomotic site in the midline. However, this places the "pexy" sutures in the way, making a tracheotomy and second stage decannulation difficult. We describe a modified laryngosternopexy (laryngoclaviculopexy) that can be performed with the "pexy" sutures out of the way to allow access to the trachea, and our initial experience with three patients.

Human ; Male ; Adult (a Person 19-44 Years Of Age) ; Larynx